best practice in direct payments support, tlap, 2012
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BEST PRACTICE IN
DIRECT PAYMENTSSUPPORT a guidefor commissionersRevised edition January 2012
Authors: Sam Bennett and Simon Stocktonfor the London Joint Improvement Partnership
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Contents
Executive summary 1
Introduction 2
Direct Payments support basics 3
The challenges we face 5
A model of best practice for support services 7
Making it cost effective 24
Choosing the best service 26
Concluding thoughts 31
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Executive summaryThis report was initially developed by Groundswell Partnership for the London
Joint Improvement Partnership (JIP) and published in November 2011. This revisededition is launched through the Think Local Act Personalpartnership and theLondon JIP to support commissioners in all parts of the country who are grapplingwith the same challenges of developing support services for much larger numbersof direct payments recipients. It was written with the support of the National
Centre for Independent Living (NCIL) and was informed by representatives fromLondon councils, DP support providers, people using DPs in the London area,Directors of Adult Social Services and members of the Think Local Act Personalpartnership. Key messages include:
The current drive to increase personal budgets,with direct payments as the chosen option for
increasing numbers of people, presents
significant challenges that demand new ways of
thinking about direct payments support.
Rising to the challenge will require a strategicresponse involving commissioners, providers and
people with care and support needs working
together to shape local commissioning.
In future, single service solutions are not likely tobe adequate and commissioners should look to
develop a mixed market of direct payments support.
There should always be a role for local ULOs in amixed model of support also encompassing larger
providers with the capacity and infrastructure to
meet significant growth in demand.
The scope of direct payments support shouldinclude support for people to use them for a
wide variety of purposes other than employing
staff directly. There are many examples of people
using direct payments to access work, start a
micro-enterprise or to pool their budgets to buy
services collectively. Many others can also benefit
from simply holding the purse strings and buying
services directly from registered care providers.
This report sets out a model of good practice fordirect payments support, co-produced with key
stakeholders, that provides a useful starting point
for understanding what needs to be in place and
how to know when its working.
The Choosing the best service tool inthis report will assist in local planning and
decision making.
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IntroductionIn the roll out of personal budgets, evidence has shown that people who
use Direct Payments tend to get better outcomes than people who usemanaged budgets.
The Government and the sector partnership Think
Local Act Personalhave also stressed that increasing
the take up of direct payments (DPs) should be a
key priority for councils as they continue to
transform local adult social care systems and work
towards making personal budgets available to
everyone eligible to receive them in the next twoyears. Evidence from a number of sources, including
SCIE, has found that support arrangements are vital
to the successful implementation of personal
budgets and for direct payments in particular. It has
also been noted that more consistent support is
required to encourage the take up of direct
payments by some currently under-represented
groups, such as older people.1
So what support do people need in order to take up
and use direct payments and what is the most costeffective way of commissioning and providing it? This
report, funded by the London Joint Improvement
Partnership, explores what best practice support for
direct payments looks like and the implications of the
current policy drive to increase uptake. It also looks
at different ways of thinking about cost effectiveness
in this context and provides pointers and practical
tools to assist local decision makers. The report is
aimed primarily at commissioners, but will also be
of interest to direct payments support organisations
(DPSOs), micro-enterprises working in health andsocial care, care providers, people using or
considering using direct payments and those with
a general interest in this field.
In developing this paper we worked closely with the
National Centre for Independent Living (NCIL),
people living in London using direct payments,
direct payments support organisations, local
authority commissioners, the London Self-Directed
Support Forum and from colleagues and experts
from the Think Local Act PersonalPartnership. Weare grateful to all those who contributed to this
paper and to Freya El Baz for coordinating the
research involved.
BackgroundFollowing the publication of Think Local Act
Personal, (TLAP) the London Joint Improvement
Partnership identified a number of priority areas
for development to support local councils to better
understand and respond to the challenges outlined
in TLAP, including work to undertake and evaluate
different support/brokerage models that help
people take up and use direct payments. The
project brief was to undertake an appraisal of
effective delivery of support and advice for people
using or wishing to use direct payments, to explore
the implications for commissioners and to consider
how an improved understanding of outcomes
and cost effectiveness could inform better localdecision making.
1 See SCIE Research briefing 20; The implementation of individual budget schemes in adult social care
http://www.scie.org.uk/publications/briefings/briefing20/.Also Davey et als 2007 national survey of direct payments
http://www.changecards.org/evidence/direct-payments-a-national-survey-of-direct-payments-policy-and-practice-2007/
2 BEST PRACTICE IN DIRECT PAYMENTS SUPPORT a guide for commissioners
http://www.scie.org.uk/publications/briefings/briefing20/http://www.changecards.org/evidence/direct-payments-a-national-survey-of-direct-payments-policy-and-practice-2007/http://www.changecards.org/evidence/direct-payments-a-national-survey-of-direct-payments-policy-and-practice-2007/http://www.scie.org.uk/publications/briefings/briefing20/ -
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ApproachOur starting point was to co-design a framework
for understanding good practice in direct payments
support. We did this together with people using
direct payments, commissioners and DPSOs as wellas key strategic organisations with an interest in the
field, particularly NCIL and the London Self-Directed
Support Forum. We brought together a group of
people incorporating all these perspectives to co
design the framework and debate a range of issues.
This included asking people to think in some depth
about outcomes, cost effectiveness and what we
might need to measure to understand success in
delivering direct payments support. In addition,
we conducted some research into current practice
across London and beyond, exploring examples of
innovative direct payments support that help to
bring the framework to life.
We think it is very important to understand what
great support looks like for people who use or
might use direct payments and to know what a
support service should be doing to serve them well.
We have structured the report to reflect this
conviction and to provide an easy reference for
people to understand good practice in a way that
reflects the outcomes we are all aiming to achieve.
Direct Payments support basicsDirect payments support organisations have been around since at least 1997
when the first direct payments legislation was enacted. Accompanying guidanceto this and subsequent legislation has repeatedly stressed the need for councilsto provide support services for people that help them consider whether directpayments may suit them and if so, how to use them safely and effectively.
Most councils responded to this requirement by
commissioning support services to accompany local
direct payments schemes. As the market for
support has developed over the last 15 years it has
done so slowly and on a relatively small scale,operating largely at the margins of social care.
Despite its niche status, it is nonetheless quite a
mature and established market. Taken as a whole it
offers a rich and diverse range of services to people
using or thinking about using direct payments,
spanning specialist employment advice, support
planning, payroll services and peer support among
other things. Although some services have a broad
reach beyond local geographical boundaries, the
market has mostly developed as a local cottage
industry working with small numbers of people,
numbers having only recently risen to an average of
9% of adults receiving ongoing care and support.
At a local level, innovation and diversity are not the
features that would first strike people looking to
use direct payments support services. The services
people can access are mostly dependent on what
has been commissioned by the local council, and in
the current economic climate peoples experience of
support is more likely to be of overstretched
services trying hard to stay afloat with decreasing
staffing and budgets.
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Perhaps not surprisingly, there has been a significant
increase recently in the use of web-based
technologies for delivering advice and support and to
help networks of people to come together. There is
much to learn from less resource intensive approaches
that do not rely on one-to-one professional supportand use techniques that enable people to do as much
as possible for themselves and with the help of peers.
There are other innovations too, including the growth
of organisations that support people, including direct
payments recipients, to set up sustainable micro-
enterprises that create jobs and increase market
diversity. There are many great examples of people
using direct payments to become producers as well as
consumers of support services.
Typically there are three types of organisation thatprovide support to people using or thinking of
using direct payments. These are:
Councils own in-house support services
Small specialist, local services, often deliveredby user led organisations, some acting as
Centres for Independent Living (CILs)
Larger national or regional organisations thatoffer support to councils across the country,
but not necessarily as their core business.
In most instances councils commission support
individually and there is not yet a pattern of support
being jointly commissioned by multiple councils to
service a number of adjacent boroughs. We expect
that this is an area that may expand in the future,
as many boroughs are hungry to explore the
potential for services to be delivered on a sub
regional basis. In London, Westminster,
Hammersmith and Fulham and Kensington andChelsea have the most ambitious current
programme to integrate adult social care activity
across a multi-authority area, although there is as
yet no plan to jointly commission direct payment
support services at tri-borough level.
The market as it stands is not well placed to meet
the challenge of a step change in the number of
people with direct payments. If councils are to
make personal budgets available to everyone
eligible to receive them by 2013, with directpayments as the preferred delivery method, the
market for direct payments support needs to grow
and adapt beyond anything that it has experienced
in its 15 year history. Innovation needs to be
encouraged so that people have a wider range of
alternatives to traditional services, are able to come
together and combine their resources easily and can
pursue opportunities to contribute and develop
enterprising ideas. The market must also provide a
range tailored direct payments support which can
appeal to particular groups of people, including
older people and people with mental health
difficulties. The next section of the report explores
some of these issues in more detail.
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The challenges we faceThe Governments recent challenge to councils concerning personal budgets and
direct payments should not underestimated. Although councils have so farresponded confidently to the challenge of increasing personal budgets, makingdirect payments the preferred delivery method is arguably a much greater test. Inthe year to March 2011, the ADASS survey of personal budgets found that over339,000 people were receiving personal budgets (35.2%), exceeding the
government target of 30%, and nearly doubling the figure for 2010. However, thesame report noted that nearly all of the increase has been in managed budgetswith no significant increase in direct payments
This is unfortunate when one considers the
evidence that taking a direct payment substantially
increases the likelihood of people getting positive
outcomes. Most recently, the POET survey of more
than 2000 personal budget holders and their carers,
which reported in July this year and was the biggest
of its kind so far conducted, made some particularly
significant conclusions. It found not only that
personal budgets work best when delivered as
direct payments, but also that direct payments work
well for older people as well as for younger peoplewith disabilities.2 This led TLAP to state in the paper
Improving Direct Payments Deliverythat evidence
continues to suggest that direct payments are likely
to be the more beneficial approach for the majority
of personal budget holders, and that councils need
a stronger focus on direct payments delivery.
The same paper included a warning that excessive
bureaucracy has impeded overall delivery of
personal budgets, and specifically the take-up of
direct payments.3
Currently, direct payments make up less than 10p of
every 1 spent on social care in England. If we accept
the aspiration of direct payments as the preferred
way of offering a personal budget, it would seem
reasonable to assume that this might mean perhaps
50% of eligible people eventually receiving them. This
illustrates the potential scale of the task at least a
five-fold increase and within that, far higher increases
for certain client groups not well represented in the
current direct payments demographic.
Whilst this paper concentrates on direct payments
support services as an essential component of any
local strategy to increase take up, it is clear that
change of this magnitude will require a fundamental
shift in systems, processes and resources, and a drive
to develop a wider diversity of provision. In this
context, the development of an enhanced range of
better support services is only one part of the strategic
approach required, but it is nonetheless a fundamental
platform from which to support the other developments
necessary for personalisation to grow.
2 See http://www.thinklocalactpersonal.org.uk/Latest/Resource/index.cfm?cid=8993
3 Improving Direct Payments Delivery, TLAP 2011
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A number of people told us that even where there
was strong evidence of the benefits of direct
payments for local people, frontline staff and
managers often found it hard to encourage their
take up and were generally more comfortable setting
up care packages consisting of directly commissionedservices. Moreover, both staff and potential direct
payment holders were often put off by the unhelpful
and lengthy processes associated with setting them
up. Managers also expressed concern that a spike in
direct payments numbers could mean a lesser role
for frontline staff and a reduced commissioning role
for councils that could have destabilizing effects on
existing services. Combined with the perceived
increase in risk often unduly associated with direct
payments, and it is not hard to see how many
councils have struggled to make them an attractiveproposition for large numbers of people or the
frontline staff charged with offering them.
For those that have made significant efforts to
boost numbers the road has not been easy. One
issue, which has been particularly difficult to resolve
for both commissioners and providers, is the
relationship between support to take up a direct
payment and advocacy. People told us that
advocacy is a core part of what they want from a
direct payments support service, but commissioners
voiced concern about mixing advocacy with support
to take up direct payments because of perceived
conflicts of interest. A number of commissioners
told us that an unhealthy dynamic had developed
between practitioners and local user led
organisations, where referrals to support services
had sometimes come back including challenges to
the budget on offer. This has in turn led to
reluctance on the part of practitioners to refer to
external organisations.
The resultant under utilisation of support services
makes them appear very expensive and can render
them unsustainable. These issues were reflected in
the experience of numerous support providers we
spoke to that complained of complex processes and
poor referral levels, combined with inadequatecommunication with local commissioners. Despite
these issues it is worth noting that there was also
an appetite for finding ways to work together better
and to meet the new challenges in partnership.
People using direct payments told us that having
support to build their confidence to take them up
was vital, including information about how they can
be used. For some people this meant information
about purchasing support directly from care
providers, while for others it meant access to optionsthat removed or reduced their responsibilities as an
employer. In addition, knowing that ongoing support
would be available if things went wrong and having
someone to turn to who had been there and done
it were seen as pivotal factors in making it feel
possible to take the leap. None of these things is
currently available to the extent needed to support
the step change anticipated. Nevertheless, it was
striking that no one we spoke to regretted the
decision to take a direct payment. One person
captured the strength of feeling well however hard
its been, Id never go back, never.
All of these pressures are happening at a time when
Local Authorities are facing huge financial
upheavals and the pressing need to do more with
less. To meet the challenges of making direct
payments a truly mainstream, accessible and
attractive option for the majority of people, the
need for shared understanding of whats required
and a commitment to work together to achieve it
could hardly be more acute.
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A model of best practicefor support services
From the work we undertook together with people using direct payments,providers and commissioners, we compiled a list of must haves for what an idealsupport service, or range of support services, should be doing and delivering. This
includes for people who are using their own money, because many of the serviceswhich a good DPSO provides will be of equal value to people funding their ownsupport. Indeed, TLAP has stated that a councils core offering to everybody, should
include support and advice for people to help them understand how to make themost of the resources available to them, both financial and non-financial.4
This section describes the 10 key features of the people might want from direct payments support
model in some detail and includes success services. Where relevant we have included case
statements, which are the sorts of things local studies illustrating particular features of the
direct payment holders and people using their own model. The case studies are not intended to give
funds to arrange support might be saying if each a comprehensive picture of the support provided
feature of the model were working well for by the organisation described, but rather to
them. Also included are a range of suggestions highlight a particular aspect or aspects of their
for how else we might know people were getting service. We are indebted to all of thosereally great support. Taken together, these 10 key organizations that agreed to share information
features represent a co-produced view of what with us in preparing these case studies.
4 Improving Direct Payments Delivery, TLAP 2011
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1) Taking a strategic role
SUCCESS MEANS
My support service
represents me and
other people using
direct payments
and we can directly
influence how
direct payments
develop at a
strategic level.
HOW WOULD WE KNOW IT
WAS WORKING?
Shared vision with strategic partners clearlyunderstood and communicated widely
Agreed and functioning processes are inplace for capturing and representing the
views of people who use direct payments
Mutually respectful relationship with localcommissioners
Provider displays a clear leadership role in
promoting the values underpinning directpayments and promoting take up
A more diverse market for people topurchase from
Direct Payments recipients are activeproducers as well as consumers of services
WHAT IS INVOLVED?
Developing a clear vision
Formally representing theviews and interests of
particular groups
Making and maintainingstrong relationships with
commissioners and other
stakeholders
Supporting and promotingpeoples engagement in thecoproduction of local
transformation programmes
for social care
Supporting and influencinglocal decision making
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RUILS: An innovative ULO responding to a difficulteconomic climate
RUILS are a local user led organization based in the Richmond Upon Thames, a boroughwith one of the highest rates of direct payments take up in the country.
They provide an innovative range of services to promote direct payments and support people to use
them well including a personal assistant (PA) finder service and a variety of direct payments related
training for PAs, PA employers and frontline staff in the borough. Their strong local leadership and
talent for innovation recently won them an award for the best local not for profit organization at
the Richmond Local Business Awards. RUILS see themselves as having a key role in promoting the
ethos of personalisation and leading cultural change. They produce a regular high quality newsletter,
which is distributed to staff at the local authority as well as local people with social care needs. They
also make good use of social media in building and maintaining a local community of interest around
personalisation and direct payments. Over the last year, they have increasingly focused on exploring
ways to respond to the difficult financial climate by finding ways to do more with less and make both
the support they offer and the money people have as direct payments stretch further.
Most recently, RUILS staff have begun to use Skype to keep in contact with service users as an
alternative to home visits wherever possible saving valuable time and resources. They have also
run a speed-recruiting event (similar to the concept of speed dating) to help people recruit
personal assistants. A volunteer coordinator has been employed in order to make the best use
out of volunteers, and a direct payments pooling guide has been established along with a series
of seminars that people can attend to learn more about pooling their budgets.
www.ruils.co.uk
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2) Information and advice
SUCCESS MEANS
I can get the advice
and support I need
when I need it
and I can trust it
to be accurate.
HOW WOULD WE KNOW IT
WAS WORKING?
Customer surveys
Where did you hearabout questions asked
at first contact
Number of otherorganisations and community
venues holding information
and signposting
Reduction in contact hoursfor people taking up directpayments and/or reduction
in numbers needing
formal support
People have access toadvice and support outside
of office hours
WHAT IS INVOLVED?
Use of multiple channels to communicateinformation and advice about direct
payments, including new media
Accessible information in different formats
Practical step by step guides designed tominimize formal support requirements
Information and advice on a wide varietyof ways of using a direct payment
Frequently Asked Questions
Translation
Agreement by other organisations tosignpost to the service
Regular local and national updates
Available on the phone and face-to-face
Available when you need it and not just 9-5
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Penderels Trust, a large independent provider in Wandsworth
Penderels Trust is a national organisation based in Coventry that provides direct payments
support services to a number of councils in London and in other areas of the country. InWandsworth they provide most aspects of direct payments support for people in the locality,
including general help and information, specialist employment support and quarterly peer
support meetings. A separate payroll service is also commissioned and provided by Payroll
Masters. The council is looking into developing a pre-paid card system but already offers
people two different types of direct payment:
1) A standard direct payment where the service user has their own account and is personally
responsible for their direct payment
2) An assisted direct payment account where the payroll provider holds the direct payment and
the support service assists with all aspects of using it.
Penderels are making significant efforts to build good working relationships with local voluntary
organisations and charities and run monthly meetings to share information and best practice with
local organizations. Their aim is to create symbiotic relationships between all local charities and
voluntary organisations so that they no longer have to rely solely on councils for referrals.
The council also provides inclusive training aimed at frontline staff working with people using
personal budgets and direct payments which Penderels staff attend. The aim is to develop a joined
up approach to how frontline staff work and avoid confrontational patterns of working.
www.penderelstrust.org.uk
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3) Peer support
SUCCESS MEANS
I have access to
people whove
been here and
done it and I can
get hold of them
when I need to.
HOW WOULD WE KNOW IT
WAS WORKING?
People report they are able to accesssupport when they need it from
knowledgeable people who have
been there and done it
Frequency of signposting from socialwork teams to peer supporters
There being a variety of ways for peopleto engage and share their views
A growing number of peopleagreeing to provide peer support
A reduction in formal support hoursper direct payment user at set up
and for ongoing management
WHAT IS INVOLVED?
Sharing personal experiences of usingdirect payments what to look out
for, what to avoid, what has worked
well, what not so well
Encouraging people to take updirect payments
Increasing peoples ability to do asmuch as possible for themselves
with informal support
Offering ideas about support
Helping people work throughproblems
Broadening peoples supportnetworks
Building a community of expertsby experience
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Real A ULO in Tower Hamlets, building a supportservice from the local community:
Tower Hamlets commissions a local Disabled People's Organisation (DPO), Real, to work as
a one-stop-shop for people using direct payments and personal budgets. Real, which was
recently formed from the merger of two local DPOs, provides support in the following areas:
An information service which includes an advocacy and advice service and ongoing support
Guidance on setting up and managing direct payments, and an independent supportplanning function
Drop-in sessions for IT training, "being a good employer" training and volunteer programmes.
Local commissioners say the change to include independent support planning was necessary due to
the low take up of direct payments and the complexities of communicating them well to such adiverse population:
From a local perspective the social care population have not embraced direct payments and
this is partly because they have been poorly communicated, but also because of the nature of
the demography of the population a lot of work needs to be done on changing the culture.
70% of Reals client-facing staff are disabled, and the organisation has made an equal effort to
represent the diverse demographic of their local community. Many of their customers do not
speak English as a first language. As a result, Real has recruited a staff team which speaks a variety
of languages including Somali and Bengali. Real also pride themselves on staying with their
customers beyond the set up period, an important factor in building peoples confidence to usedirect payments. Real provides tailored support to enable individual direct payments holders to
track how their money is being spent and manage any changes to their support package.
The service is widely regarded as achieving positive outcomes for people that are both cost-effective
and empowering.
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4) Generic advocacy
SUCCESS MEANS
My interests are
represented
strongly and fairly.
HOW WOULD WE KNOW IT
WAS WORKING?
Advocacy is available to the full rangeof people who are using or might use
direct payments and is taken up
where appropriate
There are clear boundaries betweenadvocacy and support to take up and
use a direct payments
Referrals processes for advocacy aresimple, are well used by staff and
result in timely interventions
WHAT IS INVOLVED?
Representing the interests of peopleto statutory bodies and other fund
holders where required
Ensuring peoples voice isunderstood and heard
Supporting people and familiesto make decisions in the persons
best interest
Ensuring a clear separationbetween direct payments supportand advocacy
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5) Support planning
SUCCESS MEANS
I get the support
I need to plan for
the future and
I keep control of
the process.
HOW WOULD WE KNOW IT
WAS WORKING?
Costed plans completed withclear outcomes
People reporting betterexperiences of support more
suited to them
More plans right first timeand fewer complaints
Reduction in plans rejected
or delayed at sign-off
% of plans completedwithin agreedtimeframe/
formal resource
Reduction in formalsupport hours required to
develop plans
An increase in people doinginnovative things with the
resources available to them
People using direct paymentsto create opportunities for
themselves to contribute to
their local community
WHAT IS INVOLVED?
Taking referrals from care managementteams
Explaining support planning and its benefits
Supporting someone to develop their ownplan and use resources innovatively
Providing a range of information andpractical advice about support planning
Providing 1:1 support where necessaryand appropriate
Using person-centred thinking tools to helppeople develop plans that are right for them
Helping to ensure support plans arerobust, realistic and will help meet
agreed outcomes
Ensuring plans cover contingencies
Ensuring plans are within the availablebudget or acceptable variance
Explaining Local Authorityprocedures and ensuring plans are likely to
meet local sign-off requirements
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6) Money management
SUCCESS MEANS
I have support to
help me budget
and manage my
money that fits
my needs.
I know how I can
spend my direct
payment and I have
support to keep
records and submit
information when
I need it.
HOW WOULD WE KNOW IT
WAS WORKING?
Reviews show people are makinggood use of their budgets to meet
assessed needs and outcomes
People report a smooth andstraightforward experience opening
and managing bank accounts
People able to budget effectively reduction in issues reported
A clear, transparent audit trail Timely and accurate returns available
for financial monitoring and audit
Fewer issues raised from financialmonitoring and audit
Reduced staff time on financialmonitoring and audit
Fewer complaints
Absence of concerns about financialabuse for people receiving direct
payments
WHAT IS INVOLVED?
Support to match available budgetto assessed needs and outcomes
Helping people make the most oftheir budget by drawing on other
financial and non-financial resources
where available
Support to open a dedicatedbank account
Support to manage a dedicatedbank account, including managingaccounts on behalf of people where
necessary and appropriate
Support with budgeting: saving andensuring funds are set aside for
holidays, contingencies etc
Helping people understand local rulesand flexibilities around spending
Helping people understand local
accounting requirements, keep therecords needed and complete
monitoring returns
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OCS365: a complete solutions provider for pre paidcard schemes
Staff now working for OCS365 were a major part of the team which developed East
Cheshire Councils pre pay card scheme, a project which won the Council an MJ award
in 2011 in the category of Personalisation and Choice. Pre-paid cards themselves have
been around for some years but have recently seen a resurgence of interest and a number
of London Councils have now either set up or are in the process of setting up local
card schemes.
Pre-paid cards can offer benefits to both councils and people using direct payments. For councils,
they offer a simplified audit trail and reduced paperwork for setting up and monitoring direct
payments. They can also help to reduce financial risk because the cards tend not to have overdraft
facilities. For people using direct payments, the need to open a separate bank account is removed
and paper-monitoring returns become simpler or even redundant.
Such schemes can however be controversial as councils are able to control expenditure categories
in ways that can be restrictive. Some schemes for instance restrict the card holder to purchasing
services from a discreet set of providers which runs counter to direct payments guidance and
would not be recommended. Not all councils do this however and some cards are able to be
used with any provider as well as at ATMs, making them highly flexible.
So long as they are not used in restrictive ways, pre-pay cards can be a useful additional option
for people who dont want the hassle of setting up their own bank account and submitting
paper returns.
Unsurprisingly in the current climate, providers such as OCS365 focus their offer on the
significant savings they say councils can realise to back office functions from implementing a
local prepaid card scheme. They also offer a companion card, which can be used by a trusted
carer if the direct payment recipient has difficulty in conducting transactions directly. OCS365
also offer a training package for in house staff and providers involved in implementing
local schemes.
www.ocs365.co.uk
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7) Employment advice and support
SUCCESS MEANS
I feel confident to
employ people if
I want to but I
know there are
other non-
employment
options I can use
which still give
me control.
HOW WOULD WE KNOW IT
WAS WORKING?
Increase in number of directpayment holders employing
their own staff
People reporting betterexperiences of support more
suited to them
Growth in local PA market
People reporting they were
effectively matched to PAs,right first time
Lower PA turnover
Fewer employment tribunals
Fewer employment issues andsupport breakdowns reported
Quality checks throughmystery shopping
WHAT IS INVOLVED?
A range of accessible information andadvice in different formats
Signposting to other sources of informationand advice, including NCIL, ACAS,
Sharedlivesplus, direct.gov
Basic information and advice aboutemployment law and ability to refer to
specialists when needed
Information and advice about insuranceoptions and liabilities
Personal Assistant (PA) finder service
Offers that help people take on PAs withoutassuming employer responsibilities,
including advice on self employment,
mutuals and co-operatives
Advice and support in setting up andestablishing micro-enterprises
Information, advice and support withrecruitment, including advertising, jobdescriptions, short listing, interviews and
selection
Template contracts and terms ofemployment
Information, advice and support regardingCRB checks
Support with ongoing PA management
Payroll services
Information, advice and guidance on staffsupervision, appraisal and disciplinary issues
Good mechanisms to support people toshare their experiences about what works
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People 4 People, a 4-borough specialist employment service
Four London Boroughs, Barking and Dagenham, Havering, Redbridge and Waltham
Forest, have joined forces to commission a specialist employment service for peoplelooking to recruit personal assistants.
People 4 People, is a new venture from the not for profit care provider Outlook Care offering
services to both self-funders and direct payment holders.
The service offers a comprehensive employment matching service, providing support to both personal
assistants and to potential employers through the whole recruitment process and up to 12 months
following a successful appointment. The service charges an upfront fee of 250 to its customers
which can be paid by 12 monthly installments where required.
In response to demands from people who dont wish to take on staff directly, People 4 People haverecently expanded their service to include an Individual Support Service which works to the same ethos
but which takes on the employment responsibilities for personal assistants on behalf of the customer.
People are offered the same high levels of engagement throughout the whole recruitment process
so that they can choose the right person for them and personalise the way in which their personal
assistant works with them. If people at a later stage decide they wish to take on the employment
role themselves, they can also choose to switch to the People 4 People service.
www.people4people.org.uk
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8) Training
SUCCESS MEANS
I can get good
quality relevant
training that suits
me and helps me
feel confident
to manage my
direct payment.
HOW WOULD WE KNOW IT
WAS WORKING?
Surveys show improved publicawareness of direct payments
More disabled and older peopleinvolved in designing and delivering
training
Numbers of care managers andother stakeholders who have
received awareness training
Increased PA numbers Better staff retention
Higher levels of staff satisfaction
Training to build peoples confidenceand assertiveness is available
People understand how to takeappropriate steps to guard against
harm or abuse
WHAT IS INVOLVED?
A range of training available fordirect payment holders, e.g.
budgeting, IT skills, being an
employer, interview skills, running a
micro enterprise etc
Involving direct payment holders indesign and delivery of training
A range of training availablefor PAs
Information, advice and signpostingto other training: specialist
conditions, accredited NVQs etc
Awareness training available for caremanagers and social work teams, e.g.
what are direct payments, what
support we offer etc
Awareness raining available for otherorganisations and stakeholders
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9) Setting up support
SUCCESS MEANS
I know what services
are available and
have the help I
need to choose
things that suit me.
I can get support to
put what I want in
place and make sure
things are settled.
HOW WOULD WE KNOW IT
WAS WORKING?
People use a diverse range of services
Fewer breakdowns in support
Fewer people give up directpayments
People report good levels ofconfidence at start up
People have access to informationand advice about protecting
themselves, and what to do if they
are being harmed or abused
WHAT IS INVOLVED?
Providing information to help peoplechoose the most appropriate
provision for themselves
Supporting people to takeappropriate risks
Supporting people to developcontingency plans
Ensuring people understand how
they can get ongoing support
Making sure support arrangementsare fully established and working well
for people
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Bexley: an in house service shaping the direct payments market
In Bexley, most community based social care to older and disabled people is delivered as a
personal budget. Although not everyone takes their budget directly as cash, Bexley haveremoved all block contract provision for community based services and have concentrated on
negotiating terms with providers which people can purchase directly using their personal
budget. The results so far seem good and Bexley report seeing significant improvements
both in terms of what is available in the market and in people's satisfaction levels
Providers are adjusting to an environment without block-contracts where all support is purchased via
a persons personal budget. Spot purchases can be made directly by the councils internal brokerage
team or by people directly using a direct payment. Providers themselves have begun to focus more on
the needs of customers to keep their businesses vibrant and sustainable.
The Council hopes that this will in turn lead to savings in procurement, as an average tender process oftentake about 9 months and involves hidden costs for providers, as well as for the council. Since making the
change, Bexley have found that customers have a wider choice and suppliers are offering more flexible
services, as they start to see themselves as more directly accountable to the people who buy their services.
There are some early indications that prices have also begun to be more competitive which council officers
attribute to the market being open rather than closed and the number of complaints the council
receives from people using services has also reduced. Bexley are mindful that people also need support to
recruit staff directly and are in the process of setting up a service that will assist clients to recruit their own
staff and provide support to recruit personal assistants and provide payroll and ongoing support.
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10) Ongoing support and trouble shooting
SUCCESS MEANS
My support stays
with me. Its not
just a one off.
I know where to
get help if things
go wrong and I can
talk to people who
know what Im
going through.
HOW WOULD WE KNOW IT
WAS WORKING?
People are more confident to take upa direct payment and trust help will
be there when they need it
Contracts include provisions forongoing support including
developing peer support
Peer support and advice is availableand is used and valued
Absence of concerns about financialabuse for direct payments receivers
WHAT IS INVOLVED?
Support that stays with you beyondthe initial set up period
Having someone to talk to who hasdirect experience of using a direct
payment when needed
Help when staff breakdowns occur
Specialist advice on tap just in case
Ongoing and up to date advice for
people who are employing staff orrunning a micro-enterprise
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Making it cost effectiveIn the current climate, it is hard to see DPSOs growing and expanding without a
more robust approach to measuring their impact, including their cost effectiveness.The discussions we had with commissioners and providers gave the clear impressionthat there is not currently a well developed understanding of what costeffectiveness means in this context or how to go about measuring it. Where localattempts have been made, they appear to have been fairly crude and ill suited to
the purpose with both commissioners and providers struggling to articulate theirexpectations and objectives. Such a position is unsustainable. Investment in directpayments support must be increased to enable more people to safely andmeaningfully use direct payments and that cannot happen without a better shared
understanding of how to measure cost effectiveness.
Councils have historically had difficulties costing However, the study also found that the average
the type of work involved in direct payments time to complete a support plan for the ULO was
support. A comparative study of support planning 11 hours, versus 2-4 hours for care management.
published in May 2011 by the Office for Disability This raises all sorts of questions about cost and
Issues (ODI) aimed to compare care managed quality that the report was unable to answer, but it
support planning with user led support planning certainly provides food for thought.
in three council areas. Although the reportIt is not altogether surprising that councils havecontained some interesting findings, it struggledfound costing direct payments support workto make meaningful cost comparisons, largely
because of the difficulty in identifying LA staff difficult. Supporting people to take direct payments
and helping them through the process forms atime spent on support planning, but also due tosmall part of a wider set of responsibilities for adifferences in the data collected, the availability
of council data and because some activities care manager, involves a number of back office
undertaken by ULOs had no direct comparison functions and may happen over a period of weeks
or months. While costing the work is difficult, it iswithin the Local Authority. In short, they werenonetheless important to note just how criticaldoing different things, and it is hard to compare
apples with pears. good processes are in delivering support. The POET
survey found that if the processes involved in
Perhaps unsurprisingly in light of issues highlighted setting up a personal budget are complex andin previous sections on this paper, significantly poorly communicated this creates inefficiencies and
higher proportions of people chose to take direct has a major impact on peoples experience. It also
payments when doing their support planning found that most councils do not make the process
with the ULO than with care management. easy for people and that this was the single biggest
factor impacting on their outcomes.
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Similarly to the ODI report, the POET survey found
that people were more likely to get positive
outcomes and to take their personal budget as a
direct payment when supported through the
planning process by a non-statutory body. It is
therefore reasonable to conclude that councilsshould pay close attention to both simplifying
processes and valuing outside support when
devising their strategies to make direct payments
the preferred delivery method for personal budgets.
This makes the question of measuring the cost
effectiveness of commissioned direct payments
support all the more important.
So what can be done? Firstly, we think that it will
be important for commissioners, providers and
people using direct payments to come togetherto develop a shared understanding of what
outcomes are expected from great direct
payments support and how success in achieving
them should be understood and measured.
The best practice framework in this report, co
produced with council officers, providers and
people using direct payments, is a good starting
point for developing a shared language and set
of indicators at local level.
Secondly, it will be important to avoid broadassumptions about cost effectiveness when
comparing services and to ensure that any
approach is sensitive enough to account for the full
benefits of different delivery models. In particular, it
will be important to understand the broader social
returns that ULOs and other external bodies can
offer and to ensure these are given appropriate
consideration alongside comparisons of costs when
commissioning support.
Wider benefits that may not have visible or
commonly have explicit value attributed include:
Supporting people to feel confident to take updirect payments
Promoting the benefits of direct paymentsand personalisation
Empowering local communities to have a greatervoice, greater local ownership and accountability
Developing local peer support and engagement
Improving community based leadership in localtransformation programmes
Supporting people to have a good experience ofthe process of getting a personal budget
Employing disabled people.
Some of these factors might already be factored
into contracts but others might currently go un
noticed or be seen as useful side effects. We think
they will be critical factors in the success of local
direct payments programmes and should be
recognised accordingly.
Finally, we think it will be important for cost
effectiveness to be considered in the round and for
direct payments support as a whole. Snap decisionsthat favour one model over another at the expense
of a mixed economy of options should be avoided.
When local work has been done to understand the
costs and benefits of different models, it should be
possible for multiple providers to coexist and for
people to make decisions for themselves about the
model that is right for them, including the balance
between cost and quality. The next section includes
a tool to support local decision-making.
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Choosing the best service:a planning tool for commissioning
direct payments supportIn this section we provide a practical tool designed to support commissioners and localdecision makers. It will help you plan a response to the current policy drive arounddirect payments, understand your local strengths and weaknesses in relation to directpayments support, and develop an informed commissioning response that delivers
better outcomes and value for money. The three sections are loosely based aroundthe familiar commissioning cycle of understand, plan, do and review and consist of:
1) Strategic planning questions: a list of The different sections can be completed as an
questions to help you think about your current internal exercise, as the focus of several meetings or
situation in relation to direct payments and the a single workshop. However, section two in
implications of a step change in uptake particular would benefit greatly from a more
inclusive approach, working together with people2) A 10 point review: A template incorporating using direct payments, local ULOs, DPSOs and
the good practice model contained in this paper, other care providers. Groundswell Partnership havedesigned to help you assess current provision, an interest in supporting partners to get the best
identify gaps and plan specific improvements, and; out of these tools and welcome enquiries by thoseusing or planning to use them. If you would like
3) A commissioning checklist: to help you ensuremore information about how we can support you
that you develop an inclusive commissioning to make use of the tools in this paper please emailapproach to meeting the challenge ahead us at [email protected].
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Part One: Strategic planning questions
A) UNDERSTANDING WHERE WE ARE NOW THE BASICS
1) How many people use DPs right now and how does this compare to national averages?
2) What % of spend on ongoing care and support does this represent?
3) What is the segmented distribution by client group/by area?
4) What is our current investment in DP support?
5)What are the current commissioning arrangements? (Include estimates of internal resources and commissioned services)
6) What is our assessment of current capacity to respond to increased demand from DP recipients and self
funders, and how does this differ for different client groups?
7) Is there sufficient focus on supporting people to use direct payments innovatively other than employing PAs,
e.g. pooling budgets, developing microenterprises etc?
B) AGREEING STRATEGIC PRIORITIES
8) If DP numbers increased by 10%, 25% and 50% from current levels what impact would we expect
to see on other services?
9) Could increased take-up free up resources and/or lead to cost savings and if so where and over what time period?
10) What are our aspirations for DPs as a % of personal budgets? Year on year
11) What are our aspirations for DPs as a % of eligible people with ongoing support needs? Year on year
12) What practical advice and support is available to enable people to remain safe and take appropriate risks
(e.g. support for CRB checks) and is this adequate?
13) What factors will impact on our ability to deliver these projections internal/external?
14) What is our preferred market shape are we working towards a diverse market or a single solution?
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Part Two: 10 Point review
Key
features
Success statements for
people using support
How well
are we
doing?
What do
we know
about theoutcomes
Is it cost
effective?
Is it
scalable?
Commiss-
ioning
priority?
1 5
high low
1)
Taking a
Strategic
role
My support service represents
me and other people using
DPs and we can directly
influence how DPs develop
at a strategic level
1 5
poor great
for people?
2) I can get the advice and
Information support I need when I
and advice need it and I can trust it to
be accurate
3) I have access to people
Peer whove been here and done
support it and I can get hold of them
when I need to
4)
GenericAdvocacy
My interests are represented
strongly and fairly
5)
Support
planning
I get the support I need to
plan for the future and I
keep control of the process
6) I have support to help me
Money budget and manage my
management money that fits my needs. I
know how I can spend my
DP and I have support to
keep records and submitinformation when I need it
>
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Key
features
Success statements for
people using support
How well
are we
doing?
What do
we know
about theoutcomes
Is it cost
effective?
Is it
scalable?
Commiss-
ioning
priority?
1 5
high low1 5
poor great
for people?
7)
Specialist
employment
advice/
support
I feel confident to employ
people if I want to but
I know there are other
non-employmentoptionsI can use which still give
me control
8) I can get good quality
Training relevant training that suits
me and helps me feel
confident to manage my DP
9)
Setting up
support
I know what services are
available and have the help I
need to choose things, which
suit me. I can get support to
put what I want in place and
make sure things are settled
10) My support stays with me.Ongoing Its not just a one off. I knowsupport where to get help if thingsand trouble go wrong and I can talk toshooting people who know what Im
going through
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Part Three: Commissioning checklist
DESIGNING AN APPROACH YES NO
1) Do we know which elements of direct payments support are we looking to commission
(final column section 2)?2) Have we involved people using direct payments in developing the specification and agreeing
the outcomes we want?
3) Have we identified if there is capacity for the local market to respond?
4) Do we have a view of the role that different types of provider might play ULOs,
independent sector, in-house?
5) Have we chosen a proportionate approach that will ensure a level playing field (i.e. small
and local providers are not disadvantaged)?
6) Have we agreed how we will evaluate bids including the balance between quality, cost,
value for money and social returns?
MANAGING QUALITY AND PERFORMANCE
7) Have we agreed key performance indicators, how they will be measured, by whom and
how frequently?
YES NO
8) Do we know how these indicators relate to the outcomes we specified and agreed?
9) Is our approach to quality assurance proportionate without placing unduly burdensome
demands on providers?
10) Have we agreed an approach to involving people using direct payments, their carers and
families in managing quality?11) Are we keeping track of the choices people are making and keeping providers informed
so they can adapt and respond?
12) Does our approach incentivise improvement and better value for money?
13) Are we supporting people to take appropriate risks and guard against harm or abuse?
LEARNING AND REVIEW
14) Have we fixed a date for reviewing the direct payments support we deliver/commission?
YES NO
15) Have we an agreed set of outcome measures that are specific, quantifiable and attributable?
16) Have we agreed what additional qualitative information we will use to better understand
peoples experiences?
17) Have we agreed an approach to involving people using direct payments, their carers and
families in reviewing the support they receive?
18) Have we agreed an approach to communicating our learning back to frontline staff and
people using direct payments?
19) Will we be able to compare this information with similar data for personal budget holders
with managed budgets?
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Concluding thoughtsMaking direct payments the preferred delivery method for personal budgets requires
new thinking. Rising to the challenge will require commissioners, local ULOs, careproviders and people with direct payments working together to develop a sharedvision of success and a plan to commission cost effective support that meets peoplesneeds and aspirations. This needs to happen alongside work to stimulate a morediverse range of support where people can not only purchase services but also
have opportunities to contribute and to develop the market for themselves.
We think the scale of growth required and the need
to make direct payments accessible to a wider
group of people strongly suggests that a single
provider is not the answer to great direct payments
support. It is very unlikely that any one organisation
could deliver the range of support described here to
everyone who might benefit. The future should
involve diverse local markets of support with
providers working towards shared outcomes
defined through an inclusive and engaging dialogue
between commissioners, local people, providers and
community organisations.
In any mixed economy of support, there should
be a role for local ULOs whose contribution will
always be more than just service delivery.
Engagement with ULOs is essential for co
producing credible local change programmes.
Evidence also suggests that ULOs are an effective
vehicle for harnessing the intelligence and energies
of local populations to deliver peer support and
encouragement for people to take up direct
payments and that their involvement in support
planning and training is also of great value.
However, ULOs also need freedom to maintain their
independence and being tied to large volume contracts
for service delivery can conflict with their role in
representing the interests of local communities.
Maintaining the right balance has been a hard
dilemma for many local organisations. In reality,
small community based organisations often lack the
infrastructure to deliver support at scale for large
and diverse groups of people and the re-orientating
and restructuring required to do so can serve to
compromise the very culture and integrity that
makes them so valuable and distinctive in the first
place. Commissioners and ULOs should be mindful
of this dynamic when considering the preferred
market shape for direct payments support and
the role of different parties in making it happen.
We think there is an important role for bigger
organisations with established infrastructure
working in partnership with local organisations, to
deliver comprehensive support with each party
playing to their strengths. There will also be greater
roles for specialist organisations providing advice on
budget pooling and developing micro-enterprise.
We envisage a future where a diverse range of
organisations are engaged in delivering a broader
range of support to a wider variety of people.In this context there is a place for larger
organisations to provide back office support
and additional capacity to community based
organisations providing specialist advice and
support at local level.
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Although this would no doubt challenge some
sensibilities, we think a market without a range of
players would not be viable and that finding a way
to work together towards shared goals and
outcomes will provide the best chance of meeting
the challenges ahead.
Increased diversity also needs to be accompanied
by increased consistency. Research by SCIE has
shown that people with dementia and their carers,
older people and people with mental health problems
can benefit most from consistent contact with a
known, trusted person. Direct payments support
organisations will need to be able to provide this
level of continuity to successfully expand the reach
of direct payments for all groups of people.
We think there are potentially important and
complimentary roles for in-house services
but that they should not be the sole solution or
play a major role in either support planning or
promoting take up. Where in-house services exist
they should focus on coordinating local resources,promoting coproduction and representing and
the interests of direct payments holders to the
market so that the right support is available at
the right price.
Coordinating and supporting the development of
a healthy, mutually respectful, mixed economy of
support will be no small task. But this is the only
viable response and that the benefits will be
significant when we get there.
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